Senior Life Claims Adjudicator

17046

The Role

• Will be responsible for managing and performing the adjudication requirements, including but not limited to verification of coverage, booking reserves, handling reinsurance processes, confirming the occurrence of the reported loss, performing the eligibility verifications, and determining the plan process for each claim, performing the monthly reconciliation (Non-Cash, Paid, and cadency certification). Handling of claims governance function to ensure quality adherence to the defined guidelines and meet or exceed the set quality standard; delivering audit results in a timely and consistent manner, meeting department quality and production goals.
• The specific duties in this role will include, but not be limited to:* Perform regular reviews of all types of Life and PA claims (technical and financial) using standard principles.
• Ability to perform the adjudication requirement for all types of claims.
• Managing and creating financial transactions such as reserves and reinsurance.
• Managing periodical payments in a controllable way.
• Dealing and preparing all types of reports, including KPI reports, paid / rejection ratio, spouse annuity, Schedule F, Fraud, financial transactions reports, and ad-hoc analysis.
• Ability to negotiate and provide proper explanation using strong commands in both languages, Arabic and English.
• Process payment in Kyriba as approver.
• Perform monthly reconciliation of non-cash reserves on a monthly basis.
• Perform extensive follow-up to document evidence to finalize the decision.
• Perform an investigation mechanism based on severity and type of loss.
• Performing and managing OFAC and FATCA screening. In addition, manage any additional compliance requirements.
• Obtain necessary approval by creating a case summary and forwarding it to the authorized person. The summary must be supported with coverage details, loss details. course of adjudication, confirmation of the occurrence, and update the checklists.
• Handled major cases that required extensive review and investigation. The review of the full onboarding process, insurance application, medical exam, profession, beneficiary, and declaration was made.
• Perform legal and Compliance review to determine decision strength and legal issues.
• Coordinate with individual UND and group Ops to verify coverage issues, such as premium, coverage amount, misrepresentation impact, etc.
• Ensuring at all times that claims decisions are as per established policy provisions and approvals, subject to set authority limits.
• Taking full responsibility for updating the claims documents in the related systems.
• Communicate claims requirements and decisions with channels (Insured, beneficiary, brokers, agents)
• Servicing customers directly by explaining policy terms and providing all needed guidance.
• Communicating with various stakeholders that include, but are not limited to: Product, Finance, Customer Services, Compliance, IT, Operations, Sales, and Underwriting
• Responsible for conducting claims audits to ensure that effective claims controls exist.
• Presents audit findings and makes recommendations to management/stakeholders for improvements based on audit results.
• Conduct adjudicator performance review as part of scorecard & productivity assessment; provide candid and timely feedback regarding developmental and training needs; includes supporting the completion of scorecards.
• Display a detailed understanding of standard claim/review processes and workflows, providing consistency and appropriate detail in alignment with all policies & procedures, business rules, and overall departmental guidelines.
• Maintain consistent and quality production standards with consideration of specific audit and turnaround expectations.
• Ensure compliance with local regulatory requirements and regulations.
• **QUALIFICATIONS:*** Has a good medical background and insurance principles knowledge
• Good Communication skills in all forms, including bilingual ability.
• Basic accounting knowledge.
• Creative and able to suggest and implement new ways of review and process.
• Analytical mind.
• A graduate degree, preferably a medical degree.

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